HIV Prevention Among Drug Users:
A Resource Book for Community Planners & Program Managers

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Community Attitudes and Beliefs

Beliefs About Drug Use

Drug use is generally viewed as bad for individuals
and for society. Over the last 20 years, criminal penalties for the
sale and possession of drugs have increased as part of what political
leaders refer to as the "war on drugs." The growing intolerance of drug
use and fear of drug users have been accompanied by an increasingly
heated debate about programs that provide treatment and other health
care services for drug users. The approaches taken with HIV prevention
activities are often a central element of that debate.

People may agree that there is a need for HIV prevention
activities, but disagree about their goals and methods. They also may
disagree about who should have the final authority in choosing which
prevention methods to use. The core of most debate about prevention
methods is whether an "abstinence-based approach" or a "risk-reduction
approach" is most effective.

Abstinence-based approaches to HIV prevention stress
methods such as admission to a drug treatment program to help individuals.
Abstinence-based approaches oppose interventions such as bleach distribution,
syringe exchange, and increasing access to over-the-counter sale of
syringes, since these methods are not directly linked to stopping drug
use and may appear to encourage drug use.

Risk reduction (also referred to as "harm reduction")
approaches emphasize that most drug users are unable or unwilling to
stop drug use immediately and completely; that there are limited drug
treatment program "slots" available; that many drug users cannot stop
drug use even when they are enrolled in drug treatment programs; and
that many of the drug users who are able to stop using drugs may relapse.
Risk reduction approaches emphasize a variety of interventions with
drug users, particularly those who continue to use. These interventions
include providing access to sterile syringes through over-the-counter
sale from pharmacies and syringe exchange programs; stressing never
sharing syringes, water, or drug preparation equipment; emphasizing
bleach disinfection for drug users who do not have sterile syringes;
providing alcohol swabs to clean injection sites to reduce the occurrence
of abscesses; and offering hepatitis B and other vaccinations to active
drug users.

Views on the best approaches to deal with HIV prevention
among IDUs vary dramatically at both the community and national level.
Case Example 4.1 highlights some viewpoints on the appropriateness of
HIV prevention activities.

Case Example
4.1

Opposing Views on HIV Prevention
Approaches

"Our gains against drug use have been hard-won,
and this is no time to jeopardize them by instituting needle exchange
programs. Despite all the arguments made by proponents of needle exchange,
there is no getting around the fact that distributing needles facilitates
drug use and undercuts the credibility of society's message
that using drugs is illegal and morally wrong."

Source: Martinez,1992.

"The predominant policy approach has characterized
drug use as a criminal rather than a public health problem....Those
who find it impossible to stop using drugs, or relapse following a
period of abstinence from drugs, must be encouraged to practice
safer sex and safer drug use and must be taught how to do so....Legal
barriers to the purchase and possession of injection equipment should
be removed. Legal barriers...limit the availability of new, clean
injection equipment, thereby encouraging the sharing of injection
equipment, and the increase in HIV transmission."

Source: National
Commission on AIDS, 1991.

The
Importance of Community Attitudes Regarding HIV Prevention Interventions

The HIV epidemic has had a disproportionate impact
on certain communities, particularly minority communities. In some communities,
such as youth, the rapidly growing impact of HIV infection portends
an important future public health concern. A broad range of HIV prevention
efforts have been launched to respond to this situation, and communities
have differed in their reactions. Even within communities, opinions
and support can vary widely. For example, some African American leaders
believe that HIV has been deliberately introduced into the African American
community as a form of racial genocide and are suspicious of government
prevention efforts (Thomas et al., 1993). At the same time, others support
a full range of HIV prevention measures. This section of PART 4 provides
two examples of differing attitudes toward HIV prevention efforts. They
illustrate for prevention planners and program managers the fundamental
importance of understanding the community's attitudes toward HIV prevention
if successful interventions are to be implemented.

A study on syringe exchange in the U.S. and Canada
conducted by the Institute for Health Policy Studies at the University
of California, San Francisco, identified four major reasons for opposition
expressed by African Americans to HIV risk reduction programs: (1) failure
to provide adequate drug treatment; (2) failure by advocates of syringe
exchange programs to meet with community leaders; (3) lack of recognition
by those who advocate syringe exchange of the negative effects of the
existing drug market and of drug use on communities of color; and (4)
failure to explain how syringe exchange can help, in the long term,
to curb the impact of drug use (Lurie et al., 1993).

In spite of skepticism expressed by some African
American leaders, many others support a full range of HIV prevention
measures. For instance, African American mayors in New York, Baltimore,
New Haven, and Washington, DC, have publicly expressed their support
for HIV risk reduction programs that incorporate access to sterile injection
equipment (Lurie et al., 1993). Joining in this support for HIV risk
reduction efforts are a number of African American-operated HIV prevention
agencies, including, for example, the Black Coalition on AIDS in San
Francisco. Some religious leaders who initially supported only abstinence-oriented
interventions have changed their position in the face of the ever-increasing
number of people of color affected by HIV.

An African American Leader Speaks Out
in Defense of HIV Risk Reduction

"I'm one who spoke out very harshly against the
distribution of condoms and the distribution of needles, saying that
it's cooperation with evil....If it's going to save lives and it's
going to allow for an arresting of this disease in our community so
that people who have heart attacks and other ailments can get into
the emergency rooms and be treated, then I think that these measures
are not bad measures and lots of us are going to have to think real
hard about how we oppose things that could stop this disease. In drastic
times, you have to take drastic actions. My prayer is that our drastic
actions will do enough quickly enough because too many people, homosexual,
heterosexual, rich, poor, educated, non-educated, male and female
are dying...."

Reverend Calvin Butts, Harlem, New YorkSource: Lurie et al.,1993.

The second illustration shows the importance of
community attitudes regarding HIV prevention programs for adolescents.
Investigators now report that the average age of those diagnosed with
AIDS has declined each year, and that an increasing number of adolescents
are becoming infected with HIV (Rosenberg, 1994). Comprehensive studies
have also made it clear that drug use plays an important role in HIV
infection among adolescents. In fact, 23 percent of all cases of adolescents
diagnosed with AIDS are directly attributable to injection drug use
or to sex with individuals who inject drugs (CDC, 1995). NIDA's Monitoring
the Future survey, an annual study of the prevalence of drug use among
U.S. adolescents, indicates that drug use among 8th, 10th, and 12th
graders increased in 1994, continuing the growth seen in 1993. Although
the sharpest rises in drug use were for marijuana, other substances,
such as cocaine, showed significant increases as well (Johnson et al.,
1995).

The debate over what is an appropriate approach
to HIV prevention among adolescents is heated. Community support for
or opposition to educational programs about human sexuality and about
drugs can be a critical element in the success or failure of an HIV
prevention intervention. Case Example 4.2 illustrates the power of community
opposition.

Case Example 4.2

Community Opposition to Condom
Distribution in Schools

The superintendent of public schools in a large
northeastern city supported a program making condoms available in
the city's high schools because of the high prevalence of sexually
transmitted diseases, including HIV, among the city's adolescents.
Strong parental opposition contributed to his dismissal and to the
abrupt discontinuation of the program.

Source: Blair et
al., 1994.

In other communities, however, parents and school
officials have expressed strong support for a comprehensive approach
to sex education for youth that includes equipping young people with
knowledge and decision-making skills. In some communities, this includes
support for efforts to make condoms available through school-based,
school-wide, or district-wide health programs. Table 4.1 lists a number
of cities where condoms are now available through school-based programs.

The
Advocates for Youth (formerly the Center for Population Options,
Washington, DC) estimate that condoms are now available to sexually
active students in more than 100 school-based health clinics
in the following communities:

Little Rock,
AR

Chicago, IL

Jackson, MS

Portland, OR

Culver City,
CA

Boston, MA

Portsmouth, NH

Philadelphia,
PA

Los Angeles,
CA

Cambridge, MA

Espanola, NM

Dallas, TX

Miami, FL

Baltimore, MD

Taos, NM

Houston, TX

Quincy, FL

Readfield, ME

New
York, NY

In addition to understanding community attitudes
toward HIV prevention programs for adolescents, prevention planners
and program managers need to have a thorough knowledge of the laws and
regulations regarding HIV prevention activities for adolescents. These
include the need for parental consent to administer medical care to
minors except for those deemed "emancipated" by the courts. These youth
have been legally released from the supervision of their parents. However,
in every state there are now laws that permit minors to give their own
consent for certain health services, which may include those related
to STDs and other infectious diseases. Those states that consider HIV
or AIDS either an infectious or sexually transmitted disease often permit
adolescents to provide their own consent for receiving HIV prevention
counseling and testing.